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CNS Imaging of Metastatic MelanomaCNS Imaging of Metastatic Melanoma
Sonali Mukherjee, Harvard Medical School Year IIISonali Mukherjee, Harvard Medical School Year IIIGillian Lieberman, MDGillian Lieberman, MD
May 2006Sonali Mukherjee, HMS IIIGillian Lieberman, MD
UpToDate 2006
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OutlineOutline
MelanomaMelanoma
BackgroundBackground
Epidemiology of CNS MetastasesEpidemiology of CNS Metastases
Imaging Modalities and Indications Imaging Modalities and Indications
ContrastContrast--enhanced MRI enhanced MRI
Melanin and Hemorrhage: The Diagnostic DilemmaMelanin and Hemorrhage: The Diagnostic Dilemma
Clinical Image ExamplesClinical Image Examples
Patient Presentation: Patient Presentation: A Tale of Two MetastasesA Tale of Two Metastases
SummarySummary
Sonali Mukherjee, HMS IIIGillian Lieberman, MD
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MelanomaMelanoma
Melanoma is a cancer of melanocytes, or melanin Melanoma is a cancer of melanocytes, or melanin producing cells derived from the neural crest.producing cells derived from the neural crest.
Projected lifetime risk of developing melanoma in the Projected lifetime risk of developing melanoma in the United States is 1/75.United States is 1/75.
Melanoma has widespread metastatic potential.Melanoma has widespread metastatic potential.
Preferential sites include:Preferential sites include:
Lymph nodesLymph nodes
LungLung
LiverLiver
BrainBrain
SpleenSpleen
KidneysKidneys
GI tractGI tract
Subcutaneous tissuesSubcutaneous tissues
Sonali Mukherjee, HMS IIIGillian Lieberman, MD
http://rad.usuhs.mil/derm/lecture_notes/Images/melanoma.JPG
Malignant Melanoma
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Epidemiology of CNS Metastatic MelanomaEpidemiology of CNS Metastatic Melanoma
Melanoma metastasizes to the central nervous system Melanoma metastasizes to the central nervous system more frequently than any other malignancy.more frequently than any other malignancy.
Third most common cause of brain metastases in the US Third most common cause of brain metastases in the US (after lung and breast.)(after lung and breast.)
Average time between first diagnosis of cutaneous Average time between first diagnosis of cutaneous melanoma and CNS metastasis is 45 months.melanoma and CNS metastasis is 45 months.
1212--20% of patients present with their first metastasis to 20% of patients present with their first metastasis to the CNS.the CNS.
Brain metastasis is found in 50% of patients with widely Brain metastasis is found in 50% of patients with widely disseminated melanoma.disseminated melanoma.
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Treatment of CNS Metastatic Treatment of CNS Metastatic MelanomaMelanoma
Palliative treatment includesPalliative treatment includes
Surgical removal of lesionsSurgical removal of lesions
Tumor Tumor debulkingdebulking
Whole Brain Radiation TherapyWhole Brain Radiation Therapy
BiochemotherapyBiochemotherapy
Stereotactic Stereotactic RadiosurgeryRadiosurgery
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Imaging of CNS MetastasesImaging of CNS Metastases
IndicationsIndications
Neurologic symptomsNeurologic symptoms
R/O brain metastases prior to beginning some chemotherapy regimeR/O brain metastases prior to beginning some chemotherapy regimens ns (concern for brain toxicity.)(concern for brain toxicity.)
1818FDG PET CT is not appropriate for detecting metastasis because oFDG PET CT is not appropriate for detecting metastasis because of f the physiologic uptake of the physiologic uptake of 1818FDG by the brain. FDG by the brain.
Contrast Enhanced MRI studiesContrast Enhanced MRI studies recommended recommended
Identify CNS metastasis missed by CTIdentify CNS metastasis missed by CT
Examine metastatic involvement of the spinal cord and Examine metastatic involvement of the spinal cord and leptolepto--meningesmeninges..
Melanoma has a unique tendency to hemorrhage.Melanoma has a unique tendency to hemorrhage.
MR can document presence of blood, approximate age of hemorrhageMR can document presence of blood, approximate age of hemorrhage
Three categories of signal intensity patterns seen on MRI for Three categories of signal intensity patterns seen on MRI for metastatic melanoma to the brain.metastatic melanoma to the brain.
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Three SI patterns of CNS melanoma metastasisThree SI patterns of CNS melanoma metastasis
Melanotic Metastasis*Melanotic Metastasis*
Amelanotic MetastasisAmelanotic Metastasis
Metastasis w/ Hemorrhage Metastasis w/ Hemorrhage dependent on hemorrhagic progressiondependent on hemorrhagic progression
Sonali Mukherjee, HMS IIIGillian Lieberman, MD
Signal on T1Signal on T1 Signal on T2Signal on T2
= increased signal intensity= increased signal intensity
= decreased signal intensity= decreased signal intensity
* 10% of the tumor cells must have melanin* 10% of the tumor cells must have melaninin order for the MRI to show this signal pattern.in order for the MRI to show this signal pattern.
KeyKey
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Metastasis with hemorrhage: Metastasis with hemorrhage: The diagnostic dilemmaThe diagnostic dilemma
STAGESTAGE T1T1 T2T2 TIME FRAMETIME FRAME STATE OF HGBSTATE OF HGB
HyperacuteHyperacute < 12 hrs< 12 hrs IC oxyIC oxy--HGBHGB
AcuteAcute 11--3 d3 d IC IC deoxydeoxy--HGBHGB
Early Early subacutesubacute 33--7 d7 d IC metIC met--HGBHGB
Late Late subacutesubacute 44--7 d to 1 mo7 d to 1 mo EC metEC met--HGBHGB
Chronic hemorrhageChronic hemorrhage 1 mo to yrs1 mo to yrs HemosiderinHemosiderin
Sonali Mukherjee, HMS IIIGillian Lieberman, MD
= = isoiso to hypoto hypo--intenseintense = Hyper= Hyper--intenseintense = Hypo= Hypo--intenseintense
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Metastasis with Hemorrhage: Metastasis with Hemorrhage: The diagnostic dilemmaThe diagnostic dilemma
How do you differentiate melanin in a tumor from a How do you differentiate melanin in a tumor from a simple hematoma?simple hematoma?
Heterogeneous SI patternsHeterogeneous SI patterns
(indicates multiple stages of hematoma aging.)(indicates multiple stages of hematoma aging.)
Slower evolution of the hemorrhagic tumor Slower evolution of the hemorrhagic tumor
Reduced, absent, or irregular Reduced, absent, or irregular hemosiderinhemosiderin--laden rim laden rim
Persistent edema in the Persistent edema in the subacutesubacute and chronic stages.and chronic stages.
(acute simple hematomas only have transient edema.)(acute simple hematomas only have transient edema.)
Administer contrast!Administer contrast!
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LetLet’’s look at some images to illustrate s look at some images to illustrate these three categories of MR signal these three categories of MR signal intensity patterns in CNS metastatic intensity patterns in CNS metastatic
melanoma.melanoma.
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Melanotic Pattern: T1 weighted imageMelanotic Pattern: T1 weighted image
Sonali Mukherjee, HMS IIIGillian Lieberman, MD
http://radiographics.rsnajnls.org/cgi/content/figsonly/21/3/625http://radiographics.rsnajnls.org/cgi/content/figsonly/21/3/625
Companion Patient #1:Companion Patient #1:54 y.o. male w/ 54 y.o. male w/ hxhx of acral of acral lentiginous melanoma of lentiginous melanoma of the distal thumbthe distal thumb
Melanotic melanoma Melanotic melanoma appears as homogeneous, appears as homogeneous, wellwell--circumscribed, circumscribed, hyperintensehyperintense nodules on T1 nodules on T1 images.images.
Axial T1Axial T1--weighted MR w/o contrastweighted MR w/o contrast
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Melanotic Pattern: T2 weighted imageMelanotic Pattern: T2 weighted image
Sonali Mukherjee, HMS IIIGillian Lieberman, MD
http://radiographics.rsnajnls.org/cgi/content/figsonly/21/3/625http://radiographics.rsnajnls.org/cgi/content/figsonly/21/3/625Axial T2Axial T2--weighted MR w/o contrastweighted MR w/o contrast
Companion Patient #1Companion Patient #1Same axial slice as Same axial slice as previous T1previous T1--weighted weighted imageimage
Nodules are Nodules are hypointensehypointense on on T2T2--weighted image, weighted image, surrounded by areas of surrounded by areas of edemaedema
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Amelanotic pattern: T1 weighted imagesAmelanotic pattern: T1 weighted images
Sonali Mukherjee, HMS IIIGillian Lieberman, MD
http://radiographics.rsnajnls.org/cgi/content/figsonly/21/3/625http://radiographics.rsnajnls.org/cgi/content/figsonly/21/3/625
Companion Patient #2:Companion Patient #2:40 year old male with metastatic melanoma40 year old male with metastatic melanoma
Axial T1Axial T1--weighted MR w/o contrastweighted MR w/o contrast Axial T2Axial T2--weighted MR w/o contrast weighted MR w/o contrast
Amelanotic melanoma metastasis appears as wellAmelanotic melanoma metastasis appears as well--circumscribed nodules with circumscribed nodules with hypointensehypointense signal on T1, and signal on T1, and hyperintensehyperintense signal on T2.signal on T2.
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A Tale of Two MetastasesA Tale of Two Metastases:: A Patient PresentationA Patient Presentation
Sonali Mukherjee, HMS IIIGillian Lieberman, MD
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CC: aphasia, RCC: aphasia, R--sided blurry visionsided blurry vision
KR is a 35 year old male with a history of metastatic melanoma wKR is a 35 year old male with a history of metastatic melanoma who ho presented in 2005 with two acute episodes of presented in 2005 with two acute episodes of expressive aphasiaexpressive aphasia and and rightright-- sided blurry visionsided blurry vision..
Difficulty saying the word Difficulty saying the word ““TAXTAX”” (said (said ““PAXPAX”” w/ a w/ a ““PP””.).)
Patient saw a blurry blue line in his right visual field.Patient saw a blurry blue line in his right visual field.
Episodes lasted 10Episodes lasted 10--15 minutes each, occurred three days apart. Symptoms 15 minutes each, occurred three days apart. Symptoms spontaneously resolved. spontaneously resolved.
Neurologic ROS was o/w negative.Neurologic ROS was o/w negative.
Head MR w/ and w/o contrast was performed after second episode.Head MR w/ and w/o contrast was performed after second episode.
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Patient KR: Metastasis #1 Patient KR: Metastasis #1 Left parietal metastasis with hemorrhageLeft parietal metastasis with hemorrhage
Sagittal T1-weighted MR w/o contrast
Nodular area of heterogeneous hypo- and iso-intensity surrounded by a ring of well-circumscribed hyperintensity.
Axial T1-weighted MR w/o contrast
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Patient KR: Metastasis #1Patient KR: Metastasis #1
Sagittal T1-weighted MR with contrast
Rim enhancement is seen with administration of Gadolinium-DTAP.Focal specks of hyperintensity noted centrally.
Axial T1-weighted MR with contrast
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Patient KR: Metastasis #1Patient KR: Metastasis #1
Axial T2-weighted MR w/o contrast
Sonali Mukherjee, HMS IIIGillian Lieberman, MD
Fairly homogeneous, nodular central hypointense signal
Focal specks of hyperintense signal centrally
Surrounding area of homogeneous, hyperintense signal extending centrifugally that follows the shape of the gyri, not seen on T1!
PACS, BIDMCPACS, BIDMC
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Patient KR: Metastasis #1Patient KR: Metastasis #1
Hemorrhagic lesion with heterogeneous signal intensity.Hemorrhagic lesion with heterogeneous signal intensity.
Identified three probable hemorrhagic stagesIdentified three probable hemorrhagic stages
Acute (Predominant)Acute (Predominant)
Early Early subacutesubacute vs. melaninvs. melanin
Late Late subacutesubacute vs. vs. amelanoticamelanotic
Surrounded by persistent edemaSurrounded by persistent edema
Diagnostically appears to be a hemorrhagic tumor.Diagnostically appears to be a hemorrhagic tumor.
Given history and radiology findings, likely metastatic melanoma to the brain.
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Two days later, Patient KR underwent a Two days later, Patient KR underwent a craniotomy for removal of the craniotomy for removal of the
hemorrhagic left parietal metastasis.hemorrhagic left parietal metastasis.
A Head MR was obtained A Head MR was obtained 24 hours s/p surgery.24 hours s/p surgery.
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Patient KR s/p surgeryPatient KR s/p surgery
Sonali Mukherjee, HMS IIIGillian Lieberman, MD
Axial T1Axial T1--weighted MR with contrastweighted MR with contrast Coronal T1Coronal T1--weighted MR with contrastweighted MR with contrast
Note the resection site, the subdural hematoma along the left Note the resection site, the subdural hematoma along the left hemisphere, and the posthemisphere, and the post--surgical effects on the skull.surgical effects on the skull.
PACS, BIDMCPACS, BIDMC
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Differential Diagnosis for Hemorrhage in the BrainDifferential Diagnosis for Hemorrhage in the Brain
NeoplasmNeoplasm
Primary Primary
MetastasisMetastasis
AVMAVM
Hemorrhagic venous infarction Hemorrhagic venous infarction
Hypertensive vascular diseaseHypertensive vascular disease
Stroke (Hemorrhagic) Stroke (Hemorrhagic)
Trauma to head Trauma to head
Aneurysm, Berry vs. InfectiousAneurysm, Berry vs. Infectious
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Differential Diagnosis for Hemorrhagic Metastasis Differential Diagnosis for Hemorrhagic Metastasis in the Brainin the Brain (M A T C H)(M A T C H)
M M elanomaelanoma
A A naplasticnaplastic lung carcinomalung carcinoma
T T hyroidhyroid carcinomacarcinoma
C C horiocarcinomahoriocarcinoma
H H ypernephromaypernephroma..
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3 months later, during a 3 months later, during a followfollow--up head MR study on up head MR study on
Patient KRPatient KR……
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Patient KR: Metastasis #2Patient KR: Metastasis #2 Right Right parietoparieto--occipital metastasis with hemorrhageoccipital metastasis with hemorrhageSagittal T1-weighted MR with contrast Axial T1-weighted MR with contrast
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Patient KR: Metastasis #2Patient KR: Metastasis #2
Axial T2-weighted MR w/o contrast Axial T2-weighted MR w/o contrast
Note the worsening edema, the decreasing central intensity, and the incomplete ring of hypointensity on the later image
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Metastasis #2Metastasis #2
Lesion w/ heterogeneous SI, mostly Lesion w/ heterogeneous SI, mostly hyperintensehyperintense on both T1 and T2, on both T1 and T2, indicating a late indicating a late subacutesubacute hemorrhage.hemorrhage.
Decreasing SI on T2 indicates that the hemorrhage is beginning tDecreasing SI on T2 indicates that the hemorrhage is beginning to progress o progress into a chronic stage.into a chronic stage.
Incomplete ring of Incomplete ring of hemosiderinhemosiderin noted.noted.
Edema is significantly worsened on subsequent MR.Edema is significantly worsened on subsequent MR.
Hemorrhage is evolving slowly.Hemorrhage is evolving slowly.
Lesion represents hemorrhage into a tumor that is not resolving.
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Two months later, Two months later, after experimental chemotherapy with after experimental chemotherapy with
oral oral temozolamidetemozolamide……
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Patient KR: Metastasis #2 has decreased in size Patient KR: Metastasis #2 has decreased in size and the edema has resolved.and the edema has resolved.
Axial T2-weighted MR w/o contrastAxial T2-weighted MR w/o contrast
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SummarySummary
Imaging of CNS metastatic melanoma is an important clinical Imaging of CNS metastatic melanoma is an important clinical problem. problem.
Contrast enhanced MRI is the preferred modality for imaging CNS Contrast enhanced MRI is the preferred modality for imaging CNS metastatic melanoma. metastatic melanoma.
Recognize three different intensity patterns: Recognize three different intensity patterns:
MelanoticMelanotic
AmelanoticAmelanotic
Metastasis with hemorrhage Metastasis with hemorrhage
Melanoma is common: you will take care of these patients, Melanoma is common: you will take care of these patients, regardless of your field of medicine! regardless of your field of medicine!
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AcknowledgementsAcknowledgements
Larry Larry BarbarasBarbaras, webmaster , webmaster
Gillian Lieberman, MDGillian Lieberman, MD
AtifAtif ZaheerZaheer, MD , MD
Pamela Lepkowski Pamela Lepkowski
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Remember your Remember your ABCDsABCDs……Sonali Mukherjee, HMS IIIGillian Lieberman, MD
WomenWomen’’s Health: Skin Cancer. s Health: Skin Cancer. http://www.southeastmissourihospital.com/health/adult/women/skinhttp://www.southeastmissourihospital.com/health/adult/women/skincaus.htmcaus.htm